The Role of Nursing in Hospital Activity and Mobility (AMP): Overcoming Barriers and Engaging the Team

Eleni Flanagan, DNP, MBA, RN-BCMichael Friedman, PT, MBA

hopkinsmedicine.org/pmr/amp @hopkinsAMP

Disclosure

No relevant financial or other relationships to disclose.

Please - Not for replication or reuse without expressed consent by author.

Did you attend the previous webinars on Activity and Mobility Promotion (AMP)?

• Yes• No

What discipline are you?

• Nursing• Physician/Provider• Rehabilitation• Social Work/Case Management• Administration• Other

Objectives

• Discuss the role of Nursing in hospital mobility.• Identify methods to overcome barriers to mobilizing

patients.• Identify strategies to incorporate mobility promotion

into the daily nursing workflow

Johns Hopkins Medicine

Activity and Mobility Promotion (AMP)

AMP Solutions:

Learn more: www.hopkinsmedicine.org/pmr/amphopkinsamp@jhmi.edu @hopkinsamp

Education @ Hopkins

2nd Annual Hospital Mobility ConferenceMarch 11-12, 2019For more info: bit.ly/AMP-workshop • Tools and Resources

• AMP QI Coaching• Visitor Program• On-site Consulting

Bedrest is Bad

• Skeletal muscle atrophy and weakness– Muscle mass decreases by ~1.5-2% per day during bed rest.

• Joint contractures– 61 of 155 (~40%) patients with contractures who survived a

critical illness• Thromboembolic disease

– Virchow’s triad: blood flow, vascular injury, and coagulopathy.• Atelectasis

– Atelectasis may predispose to pneumonia, and it raises pulmonary vascular resistance.

• Pressure ulcers– In supine subjects, raising the head of the bed causes greater

pressure at the skin-bed interface in the sacral region

Body Systems:

Disease

DebilityCo-morbidity

Brower. CCM 2009

Hospital Outcomes

Hospital-acquired physical impairment is associated with INCREASED:

• Hospital-acquired complications• Hospital LOS• 30-Day readmissions• Nursing home and rehab stays• Long-term impaired physical function

Covinsky et al. J Am Geriatr Soc. 2003; 51: 451-458. Brown et al. J Am Geriatr Soc. 2004; 52: 1263-1270. Brown et al. JAMA. 2013; 310: 1168-1177.Hoyer et al. J. Hosp. Med. 2014; May;9(5):277-82

Disease

DebilityCo-morbidity

AMP QI Model Pre-Implementation• Establish multi-D AMP QI team & schedule• Establish measurement analytics plan• Functional assessment EMR integration• Patient & staff messaging plan• Administer Mobility Barriers Survey• Staff & Provider Education

Implementation Phase • Consistent barrier and data review• Daily Mobility Goal Setting• “Choose Wisely” for PT/OT Consults• Documentation compliance • Program Evaluation • Messaging and promotion

Program Sustainability and Enhancement• Integrate into employee orientation• Integrate into Safety/Quality• Integrate into Capacity and Throughput• Continual Analytics Review• Integrate Clinical Pathways

Pronovost, Berenholtz, Needham, BMJ 2008; 337:a1714.

Themes Influencing Delivery of Physical Activity

Parry et al. 2017

Early mobility

• Safe• Effective• Associated with better outcomes

Risks of low mobility

• Deconditioning• Weakness• Functional disability • Venous thromboembolism (VTE)• Pressure injuries• Increased length of stay• Movement to higher level of care

Patient Level Barriers

• Medical instability • Risk of dislodgement • Cognitive impairment • Physical restraints• Sedation• Inadequate analgesics• Obesity

Anekwe, et al. (2019). Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada. Journal of Intensive Care Medicine. 34(3), 218-226.

Provider Level Barriers

• Limited staffing• Not a priority• Not supported• Communication between providers• Decision-making authority• Safety concerns• Inadequate training to facilitate mobility

Anekwe, et al. (2019). Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada. Journal of Intensive Care Medicine. 34(3), 218-226.

“Walking The Process”

• Identify focus of observation

• Observe work process to build knowledge of current state

• Stay generalizable and reproducible

• Observe to learn, NOT to fix- Remain objective

• Identify potential barriers and defects in delivering intervention

• Engage staff- Provide support and feedback

• Three 4-hour Direct observations• Performed in Medical ICU• 2 Nurses, 1 clinical technician• RN to patient ratio 2:1• 194 distinct tasks observed within 4

categories of RN work• Patient care (47% of observed time)• Provider communication (25%)• Documentation (18%)• Down time (10%)

18% of tasks missed potential mobility activities:

• Meals in a chair• Bedside commode use• Assist in rolling• Participation in ADLs• Edge of bed for assessments

“…In retrospect, mobility was possible, but not performed, because nurses ‘just don’t think to

do it.’”

Observation Takeaway And Feedback

• Nursing staff have limited time for additional clinical activities

• Potential opportunities exist to incorporate patient activity and mobility into existing patient care

• Integrating mobility into patient activity is our greatest opportunity to achieve results for the patient and make work easier for the nurse

• Additional education and engagement is necessary to achieve nurse facilitated patient activity and mobility

Barrier Identification

• Debrief with staff• Discuss workflow and perceived barriers individually• Encourage conversation• Act on what you promise

Staff Debrief

• Debrief with multidisciplinary group in each area/unit• Try for high attendance but you don’t need everyone• Plant a seed (power of influence) • Listen (Don’t solve their problems)• Be open to ideas (don’t negate anything)• Allow them to be solution driven

Question % D/SD N

% A/SA

%

1 My patients are too sick to be mobilized 67% 15% 18%

2 I have received training on how to safely mobilize my inpatients 18% 21% 61%

3 Increasing mobilization of my patients will be harmful to them (i.e. falls, IV line removal, etc).

79% 15% 6%

4 A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients

45% 15% 39%

8 The physical functioning of my inpatients is regularly discussed between the patient’s healthcare providers (nurses, physicians, physical therapists, occupational therapists)

0% 15% 85%

9 Nurse-to-patient staffing is adequate to mobilize patients on my unit. 70% 15% 15%

11 Unless there is a contraindication, my patients are mobilized at least once daily by nurses.

36% 24% 39%

12 Increasing mobilization of my inpatients will be more work for nurses 18% 9% 73%

15 Increasing the frequency of mobilizing my patients increases my risk for injury. 39% 18% 42%

18 I believe that my patients who are mobilized at least once daily (if there is no contraindication) will have better outcomes.

0% 0% 100%

21 I do not feel confident in my ability to mobilize my inpatients 76% 12% 12%

Debrief themes

* Allow them to vent but redirect into possibility thinking• “We don’t have the time to mobilize patients”• “We will get hurt by mobilizing some patients”• “Our falls are already high, this will increase falls”• “It takes everyone on the unit to get this person up”• “Why doesn’t PT do this?”

Bright ideas

• Night shift gets all capable patients up for breakfast• Sitting up for breath sounds • Encourage patient to perform ADLs• Move bedside commode farther away daily• Incorporate mobility goals into bedside reporting• Engage MDs to motivate mobility in patients• Engage family and visitors • Any mobility is some mobility

Sharing Performance Metrics

Measuring Performance

• Why is this important? • What are we measuring? • How do we measure it? • Do we have baseline data? • Mechanisms of sharing the metrics and milestones.

Importance of Measuring Performance

• Identifies current situation• Identify process efficiencies• Articulate desired results• Identification of best practices • Provides visibility and accountability• Drives success

Metrics

• Documentation compliance – HLM: 2 times/day– AMPAC: Monday, Wednesday, Friday

• Goal discussion and documentation • Goal achievement• Length of stay• Upgrades or bounce backs to higher level of care• Don’t metric overload

Unit based “Mobility Champions”

• Key to success• Power of influence• Drive commitment• Change culture

Role of AMP Super User

• Positivity • Promotes AMP initiative• Educate peers• Strong advocate for Activity and Mobility promotion• Patient centered • Influencer and change agent • Communicate barriers and solutions to promote mobility to unit and

hospital leadership • Creative and solution oriented

Staff Engagement

• Key is to involve staff on the local units• Make sure they know “why” “what” and “who”

– Why is this important?– What needs to be done? (patients don’t have to walk miles)

Set achievable goals for units and patients– Who can be involved? (hint… the entire team)

• Make sure all staff are aware of AMP initiative– Incorporate activity and mobility in normal workflow

Encouragement and Recognition

• Make it “fun” and easy• Understand that ANY mobility is better than none! • Relate it to how this affects them

– Stronger patients are healthier • This isn’t “extra work for the nurse”. This is what

nurses do. • Recognize the hard work

Mobility Poster Contest

Education and Training

• Super user • Staff Training• Partners in mobility • Annual updates review • Onboarding new employees• Charge nurse and preceptor education

On-going support

Reporting and discussion of metrics• Select metrics (only a few)• Share data with managers and staff• Highlight improvement (celebrate the wins!)• Increased documentation compliance (usually)

equates to increased patient movement and eventually, goal attainment.

On-going support

• Bi-weekly phone calls with super users– Review metrics – Discuss best practices– Understand the on-going barriers– Discuss tools needed to support staff– Solution focused

Culture Change – Sustainability

• Nurse leader “buy in”• Make activity and mobility a priority• Part of the nursing process – (Today’s work makes

tomorrow better for you and patient!)• New staff onboarding• Charge nurse/preceptor orientation• Sustained engagement of mobility champions

Recognition

Overcoming Barriers

• Listen • Focus on solutions• Identify unit based “Mobility Champions” (super users)• Provide education and training• Engagement• Ongoing support

Change culture

Summary

• Importance of mobility – reducing adverse outcomes• Identify and communicate the why, what, and how• Select, measure, and share performance metrics• Don’t overload your stakeholders• Share the information• Promote solution based discussions• Drive culture change by involving engaged frontline staff• Recognize and celebrate successes

Johns Hopkins Activity and Mobility Promotion (AMP)Publications

• Mobility and Hospital Outcomes– Hoyer EH, Needham DM, Miller J, Deutschendorf A, Friedman M, Brotman DJ. Functional Status Impairment is Associated

with Unplanned Readmissions. Archives of PM&R. 2013. Oct;94(10):1951-8. PMID: 23810355– Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of Impaired Functional Status at

Hospital Discharge and Subsequent Rehospitalization. Journal of Hospital Medicine. 2014. May;9(5):277-82. PMID: 24616216

• Systematic Functional Assessment– Hiser S, Toonstra A, Friedman LA, Colantuoni E, Connolly B, Needham DM. Interrater Reliability of the Functional Status

Score for the Intensive Care Unit. J Acute Care Phys Ther. 2018 Oct.;9(4):186–192. – Hoyer EH, Young DL, Klein LM, Kreif J, Shumock K, Hiser S, Friedman M, Lavezza A, Jette A, Chan KS, Needham DM.

Toward a Common Language for Measuring Patient Mobility in the Hospital: Reliability and Construct Validity of interprofessional Mobility Measures. Phys Ther. 2017 Nov 2. PMID: 29106679

• Barriers to Hospital Mobility– Young DL, Seltzer J, Glover M, Outten C, Lavezza A, Mantheiy E, Parker AM, Needham DM. Identifying Barriers to Nurse-

facilitated Patient Mobility in the Intensive Care Unit. American Journal of Critical Care. 2018;27(3):186–193.– Hoyer EH, Brotman DJ, Chan KS, Needham DM. Barriers to early mobility of hospitalized general medicine patients:

Survey development and results. American Journal of PM&R. 2014, Aug 15. PMID: 25133615

• Feasibility of Mobility– Pottenger BC, Pronovost PJ, Kreif J, Klein L, Hobson D, Young D, Hoyer EH. Towards improving hospital workflows: An

evaluation of resources to mobilize patients. J Nurs Manag. 2018 Aug 16. doi: 10.1111/jonm.12644. PMID: 30117210• Mobility Goals

– Klein LM, Young D, Feng D, Lavezza A, Hiser S, Daley KN, Hoyer EH. Increasing patient mobility through an individualized goal-centered hospital mobility program: A quasi-experimental quality improvement project. Nurs Outlook. 2018 Feb 27. pii: S0029-6554(17)30492-X. doi: 10.1016/j.outlook.2018.02.006. PMID: 29705382

• Targeting Rehabilitation Resources– Probasco JC, Lavezza A, Cassell A, Shakes T, Feurer A, Russell H, Sporney H, Burnet M, Maritim, C, Urrutia V, Puttgen

A, Friedman M, Hoyer E. Choosing Wisely Together: Physical and Occupational Therapy Consultation for Acute Neurology Inpatients. The Neurohospitalist. 2017.

• Function and Discharge Placement– Hoyer EH, Young DL, Friedman LA, Brotman DJ, Klein LM, Friedman M, Needham DM. Routine Inpatient Mobility

Assessment and Hospital Discharge Planning. JAMA Intern Med. 2018 Nov 26. doi: 10.1001/jamainternmed.2018.5145. PMID: 30476953

• Systematic Mobility Promotion– Hoyer EH, Friedman M, Lavezza A, Wagner-Kosmakos K, Lewis-Cherry R, Skolnik JL, Byers SP, Atanelov, L,

Colantuoni E, Brotman DJ, Needham DM. Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality improvement project. Journal of Hospital Medicine. 2016 May;11(5):341-7. PMID: 26849277

Johns Hopkins Activity and Mobility Promotion (AMP)Publications

Activity and Mobility Promotion (AMP) Solutions

AMP Solutions:

Learn more: www.hopkinsmedicine.org/pmr/amphopkinsamp@jhmi.edu @hopkinsamp

Education @ Hopkins

2nd Annual Hospital Mobility ConferenceMarch 11-12, 2019For more info: bit.ly/AMP-workshop • Tools and Resources

• AMP QI Coaching• Visitor Program• On-site Consulting